Inspection·February 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the Care Plan to ensure a fall did not occur for one (R1) resident of three residents reviewed for falls/accidents in a sample of three Findings include: The facility's Incidents and Accidents Policy, dated 12/6/22, documents: It is the policy of this facility for staff to utilize (Electronic Health Record)/Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. R1's diagnoses included: Dementia, psychotic disturbance, mood disturbance, chronic kidney disease, malignant neoplasm of bladder, chronic obstructive pulmonary disease, retention of urine, urinary tract infection, cerebrovascular disease, weakness, other abnormalities of gait and mobility, history of falling, acute kidney failure. R1's Care Plan documents: The resident has an Activities of Daily Living/ADL self-care performance deficit related to weakness. The resident has limited physical mobility related to muscle weakness, dementia. The resident has impaired cognitive function/dementia or impaired thought processes related to dementia diagnosis. R1's Fall Risk assessment dated [DATE], documents: (R1) is at high risk for falling; (R1) overestimates or forgets limits. R1's Progress Note Dated 1/20/24 documents: Ground level fall at 200 hall nursing station, resident ambulating unassisted and fell, struck right side of head with laceration noted. Resident made comfortable and will let Emergency Medical Transport/EMTs lift resident up due to head injury. R1's Report to (State) Department of Public Health, Incident Date 1/20/24, documents: R1 Attempted to self-ambulate which resulted in fall, sent to Emergency Room/ER for evaluation. Investigation initiated. Type of Injuries: Six centimeter laceration to right forehead closed with five staples. R1's Hospital Notes, dated 1/22/24 documents: Assessment: Acute nondisplaced fracture involving the right posterior lamina; acute nondisplaced fractures involving the temporal process of the right (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145600 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145600 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Canton 2081 North Main Street Canton, IL 61520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)